Carotid artery revascularization in patients with contralateral carotid artery occlusion: Stent or endarterectomy?

Background: The Centers for Medicare and Medicaid Services (CMS) considers that contralateral carotid artery occlusion puts the patients at high risk for carotid endarterectomy (CEA) and agrees to reimburse for carotid artery stenting (CAS) in these patients. However, there is a paucity of evidence that support the superiority of CAS compared with CEA in patients with contralateral carotid occlusion. Methods: All patients who underwent CEA or CAS with contralateral carotid artery occlusion were identified in the Vascular Quality Initiative (VQI) registry between 2005 and 2016. Outcomes examined were stroke, death, and myocardial infarction at 30 days and stroke and death at 2 years stratified by ipsilateral symptomatic status. Multivariable logistic regression analysis was implemented to estimate the odds ratios (ORs) of 30-day outcomes controlling for potential confounders. Life tables, robust Cox proportional hazard clustered by centers, and log-rank tests were implemented to estimate the hazard ratios (HRs) for long-term events. Results: Overall, 4326 patients had contralateral carotid artery occlusion (CEA: 3274 [75.7%] vs CAS: 1052 [24.3%]). Patients' demographic and comorbidities were generally similar in both groups, except for race, in which nonwhite patients were more likely to have CAS (9.5% vs 7.6%; P = .048). History of stroke was twice as much prevalent in patients undergoing CEA (56.4% vs 24.0%; P < .001). CAS patients were more likely to present with ipsilateral symptoms (41.2% vs 24.2%; P < .05). In asymptomatic patients, the short-term outcomes and 2-year risk of ipsilateral stroke did not differ significantly between CAS and CEA; however, the adjusted risk of any stroke or death over 2 years was 42% higher with CAS (adjusted HR, 1.42; 95% confidence interval [CI], 1.08-1.86; P = .011). In symptomatic patients, CAS was associated with an almost threefold higher risk for 30-day stroke (OR, 2.90; 95% CI, 1.06-7.94; P = .038) and more than sixfold the 30-day mortality (OR, 6.10; 95% CI, 2.20-16.92; P = .001). The risk of stroke in the initial 2 years after surgery was 94% increased in a CAS patient relative to a CEA patient (adjusted HR, 1.94; 95% CI, 1.18-3.19; P = .009). Conclusions: In this exclusive large cohort of patients with contralateral carotid artery occlusion, CAS did not perform better compared with CEA in asymptomatic patients and had significantly worse outcomes in symptomatic patients in the perioperative period. The 2-year stroke rate was similar between the two procedures, but the risk of stroke or death was consistently higher for CAS patients. CAS is not safer than CEA in patients with contralateral carotid artery occlusion, and refinement of current guidelines is warranted to provide appropriate surgical care specifically tailored for the patient's presentation.